Armed Forces Health Surveillance
Center: Medical Intelligence or
Intelligent Medicine
21 June 2011
Sharon L. Ludwig, MD, MPH, MA
CAPT, USPHS/USCG
Division Chief Epidemiology and Analysis
UNCLASSIFIED
Disclaimer
The views expressed in this presentation are those of the
author and do not necessarily reflect the official policy or
position of the US Army, Department of Defense, Coast
Guard, or the Public Health Service.
UNCLASSIFIED
Briefing Outline
1. Intelligence and Surveillance
2. Introduction to AFHSC
3. Data & Analysis
4. Public Health Practice vs Research
5. Intelligent Medicine
UNCLASSIFIED
Military Intelligence
• Military Intelligence:
•
•
“information and knowledge obtained
through observation, investigation, analysis, or understanding
Surveillance: systematic observation* for whatever data are
available
Reconnaissance: specific mission to obtain specific data
* of aerospace, surface, or subsurface areas, places,
persons, or things, by visual, aural, electronic,
photographic, or other means
UNCLASSIFIED
Military Medical Intelligence
• Tracking/assessing full range of global health issues,
•
•
specifically those that could negatively impact U.S.
military and civilian health
Uses medical/public health surveillance information
National Center for Medical Intelligence (NCMI)
UNCLASSIFIED
Public Health Surveillance
• Ongoing, systematic collection, analysis, interpretation,
•
•
•
and reporting of health related data
Purposes of detecting, characterizing, and countering
threats to the health, well-being, and performance of
defined populations [Military Services]
Followed by timely dissemination and public health action
to prevent, treat, or control disease & injury
Includes
– Medical Surveillance
– Occ/Env Health Surv
– [Military Force
Health Protection]
UNCLASSIFIED
AFHSC Established Feb 2008
DASD(HA)
Force Health
Protection &
Readiness
DoD Global
Emerging
Infections
Surveillance &
Response System
Global Health
Surveillance
Capability Area
UNCLASSIFIED
Army Medical
Surveillance
Activity
Defense Medical
Surveillance System
(DMSS)
&
DoD Serum
Repository (DoDSR)
AFHSC Governance
USD (Personnel
&Readiness)
ASD (Health Affairs)
Army Exec Agent
Force Health
Protection Council
Armed Forces Health
Surveillance Center
UNCLASSIFIED
Functional
Oversight
AFHSC Relationships
National (CDC)
Armed Forces
Health Surveillance
Center
DoD
HQ,USCG
State
Health
Depts
PHC(P)
POPM
NMCPHC
BUMED
County
/Metro
Depts
USAFSAM
AFMSA
Service
Public
Health
Ctrs
MTFs
UNCLASSIFIED
AFHSC Mission & Vision
• Mission:
To promote, maintain, and enhance the health
of military and military-associated populations by
providing relevant, timely, actionable, and
comprehensive health
surveillance information
and support.
• Vision: To be the central
epidemiological resource for
the US Armed Forces and
the Military Health System.
UNCLASSIFIED
AFHSC Scope of Responsibility
IAW CONOPS
What We Shouldn’t Do
What We Should Do
• Strategic level surveillance
• Improve decision-making and
• Direct installation surveillance
effectiveness
– Acquire, analyze, interpret,
recommend and disseminate
information
– Develop, refine, and improve
standardized surveillance
methods
– Serve as focal point for sharing
health surveillance products,
expertise and information
•
•
•
•
support
Healthcare systems analysis
Evaluation of the quality of care at
the individual provider-patient level
Clinical research
In-house laboratory services
UNCLASSIFIED
AFHSC Structure
Director
Science Advisor
HQ Staff
Deputy Director
Communications,
Standards, &
Training Division
Data Management &
Tech Support
Division
Epidemiology
& Analysis Division
PERSONNEL
Uniformed: 17
FederalCiv: 4
Contract: 63
UNCLASSIFIED
GEIS Operations
Division
AFHSC Divisions
Communications, Standards & Training
Director
Science Advisor
HQ Staff
Deputy Director
Communications,
Standards, &
Training Division
Data Management &
Tech Support
Division
Epidemiology
& Analysis Division
PERSONNEL
Uniformed: 17
FederalCiv: 4
Contract: 63
UNCLASSIFIED
GEIS Operations
Division
AFHSC Divisions
Communications, Standards & Training
UNCLASSIFIED
AFHSC Divisions
Communications, Standards & Training
Medical Surveillance Monthly Report
•
•
•
•
•
Longitudinal surveillance of health & fitness
of Service members
> 100 issues
Online and mailed each month
Annual DoD summaries
Promulgation of DOD standard case
definitions
www.afhsc.mil
UNCLASSIFIED
AFHSC Divisions
Communications, Standards & Training
AFHSC Surveillance Standards
• Part of AFHSC mission to provide guidelines and
standardization for epidemiological purposes across DoD
• AFHSC maintains the Tri-Service Reportable Medical Events
Guidelines and Case Definitions
• New “surveillance case definitions” are among first formal
efforts to document methods unique to AFHSC/Defense
Medical Surveillance System
UNCLASSIFIED
AFHSC Divisions
Communications, Standards & Training
UNCLASSIFIED
AFHSC Divisions
Communications, Standards & Training
Resident Rotations at AFHSC
• Preventive and Occupational Medicine residents
– Walter Reed Army Institute
of Research (WRAIR)
– Uniformed Services University of
the Health Sciences (USUHS)
• 4-6 week rotation w/data analysis
project using DMSS
UNCLASSIFIED
AFHSC Divisions
GEIS Operations
Director
Science Advisor
HQ Staff
Deputy Director
Communications,
Standards, &
Training Division
Data Management &
Tech Support
Division
Epidemiology
& Analysis Division
PERSONNEL
Uniformed: 17
FederalCiv: 4
Contract: 63
UNCLASSIFIED
GEIS Operations
Division
AFHSC Divisions
GEIS Operations
Strategic Goals and Priority Pillars
RI = Respiratory Infection
GI = Gastrointestinal Infection
FVBI = Febrile & Vectorborne Infection
AR = Antimicrobial Resistance
STI = Sexually Transmitted
Infection
STI
STI
DRO
AR
FVBI
GI
GI
ARD
RI
Force Health Protection
Surveillance and Response
Training and Capacity Building
Research, Innovation and Integration
Assessment and Communication of Value Added
UNCLASSIFIED
AFHSC Divisions
GEIS Operations
WRAIR/NMRC
DoD Partners
USAPHC
(Prov)
Germany
NHRC
Korea
Egypt
USAFSAM
Thailand
NMCPHC
Kenya
Peru
Pacific
UNCLASSIFIED
AFHSC Divisions
Data Management & Tech Support
Director
Science Advisor
HQ Staff
Deputy Director
Communications,
Standards, &
Training Division
Data Management &
Tech Support
Division
Epidemiology
& Analysis Division
PERSONNEL
Uniformed: 17
FederalCiv: 4
Contract: 63
UNCLASSIFIED
GEIS Operations
Division
AFHSC Divisions
Data Management & Tech Support
• Maintain Defense Medical
Surveillance System (DMSS)
• Archive HIV test results
• Maintain DOD Serum Repository
• Support AFHSC IM/IT Needs
UNCLASSIFIED
AFHSC Divisions
Data Management & Tech Support
DMSS—Longitudinal Database >1.5B Records
MEPS
12.1 million persons
26.6 M records
Personnel Data
9.4 M persons
111.7 M records
Serum
58.2 M specimens
38.9 HIV test results
Hospitalizations
2.5 M records
Pre / Post-Deployment
Health Assessments
8.5M
Discharge
or Death
Accession
Process
Immunizations
86.9 M records
Reportable Diseases
276 K records
Deployments
4.9 million records
Casualty Data
49 K Deaths
Ambulatory Data
211.7 M records
As of Feb 2011
UNCLASSIFIED
AFHSC Divisions
Data Management & Tech Support
DMSS Data Inputs / Frequency
Table
Source
Frequency
Person
DMDC
Monthly
9.4 M
1985 -- 2010
Demographics
DMDC
Monthly
109.7 M
1985 -- 2010
MEPS
MEPCOM
Monthly
37.9 M
1985 -- 2010
Deploy (PGW)
DMDC
Single
682 K
1990 -- 1991
Deploy (CENTCOM)
DMDC
Monthly
3.5 M
1993 – 2010
Deploy Forms
MEDPROS, PIMR, EDHA
Daily/Weekly
8.1 M
1996 – 2010
Inpatient-MTF/TED
DHSS
Monthly
2.5 M
1990 – 2010
Outpatient-MTF/TED
DHSS
Weekdays
201.4 M
1996 – 2010
Reportable Events
MTFs
Daily
266.8 K
1994 – 2010
Immunizations
DEERS
Weekdays
87.0 M
1980 -- 2010
DoDSR
DoDSR
Weekly
57.5 M
1985 -- 2010
Casualty
WHS / AFIP
Quarter/Month
48.7 K
1985 -- 2010
TMDS
FHP&R
Daily
4.5M
2005 – 2010
TRAC2ES (CENTCOM)
TRANSCOM/FHP&R
Weekly
72.9K
2001 – 2010
UNCLASSIFIED
Rows
Time Period
AFHSC Divisions
Data Management & Tech Support
Reportable Events Process
Provider / Lab Report
Installation / Ship
/ Unit PM
Installation / Unit
Prev Med
DRSi
Installation / Unit
Prev Med
AFRESS
Navy Environmental
PM Unit
Regional Medical
Command
Navy Marine Corps
Public Health Center
Army Public Health
Command (P)
Monthly/Weekly
AFMOA /
MAJCOM
Air Force Sch of
Aerospace Med
Weekly
Armed Forces Health Surveillance Center/DMSS
UNCLASSIFIED
AFHSC Divisions
Data Management & Tech Support
Defense Medical Epidemiology Database
UNCLASSIFIED
AFHSC Divisions
Data Management & Tech Support
DMSS & Functional Relationships
PERSONNEL DATA
MEDICAL DATA
Active Duty
Since 1990
6.6 million persons
74.9 million records
In-patient
Since 1990
2.7 million records
8.9 million records
Reserve Component
Since 1990
2.4 million persons
27.6 million records
Ambulatory
Since 1996
161.8 million records
556.9 million records
Active Duty
Casualty
Since 1980
40,600 records
Reportable Events
Since 1995
215,000 records
120,000 records
Military Entrance
Processing Stations
Since 1985
11.1 million persons
23.1 million records
Immunizations
Since 1980
51.6 million records
SEROLOGIC DATA
Deployment Rosters
Since 1990
2.6 million persons
4.0 million records
Serologic Specimens
Since 1985
9.0 million persons
46.1 million specimens
Pre and Post Deployment
Health Assessments
Since 1994
6,366114 surveys
Disease and Non-Battle
Injury (aggregate)
Since 1996
98,900 records
DMSS
Services of the Armed Forces Health Surveillance Center
Medical
Surveillance
Monthly
Reports
(MSMR)
DEPLOYMENT DATA
Monthly
Synchronization
Hospitalization
Queries
Ambulatory
Queries
Adhoc
Requests
Studies
and
Analyses
Routine
Reports &
Summaries
DMED
Version 3.6
Remote Access to DMSS data
(non-privacy act only)
DMSS: Defense Medical Surveillance System
DMED: Defense Medical Epidemiology Database
UNCLASSIFIED
Reportable
Events Queries
Personnel data
Queries
AFHSC Divisions
Data Management & Tech Support
• World’s largest serum repository
• Unrivaled potential for sero-epi studies
• ~ 40 various size sample requests/year
• 60M serial serum specimens from 10M individuals
• Linked to demographic, military, and medical information
via the DMSS
DoD Serum
Repository
UNCLASSIFIED
AFHSC Divisions
Epidemiology & Analysis
Director
Science Advisor
HQ Staff
Deputy Director
Communications,
Standards, &
Training Division
Data Management &
Tech Support
Division
Epidemiology
& Analysis Division
PERSONNEL
Uniformed: 17
FederalCiv: 4
Contract: 63
UNCLASSIFIED
GEIS Operations
Division
Epidemiology & Analysis
Customers
• Secretary of Defense
• Assistant Secretary of Defense for Health
Affairs [ASD(HA)]
• USCG Director of Health and Safety
• Joint Chiefs
• Service Surgeons General
• Service Public Health Hubs
• AFHSC Staff
UNCLASSIFIED
Epidemiology & Analysis
Data sources: DMSS, DoDSR, others
 Operational surveillance analysis (600/yr)
 Support for:
–DoD policy development
–GAO investigations
–Congressional Inquiries
 Analysis for MSMR articles
 Special Studies / Research Support
Includes specialized influenza surveillance/analysis
 Focused periodic reports (1450/yr)
UNCLASSIFIED
Epidemiology & Analysis
Example of MSMR Support
US Military Malaria Cases Jan 02-Dec 08
55
45
Other
40
Korea
35
Afghanistan
30
25
20
15
10
October
2008
July
April
January
October
2007
July
April
January
October
2006
July
April
January
October
2005
July
April
January
October
2004
July
April
January
October
2003
July
April
January
October
2002
July
0
April
5
January
Number of cases
Likely infection location
Peacekeeping
mission in
Liberia
50
Source: MSMR Vol 16, No. 1 Jan 09, AFHSC
UNCLASSIFIED
Epidemiology & Analysis
Example of Serum Study:
Hantavirus in Military Personnel from Four Corners Area
UNCLASSIFIED
Epidemiology & Analysis
May 2010: AFHSC Routine Reports*
Type
Total # Reports
Reportable Medical Events/Communicable Diseases
Deployment Health Assessments
Influenza
H1N1 Vaccine Safety and Compliance
Medical Evacuations
Deployment Health Report
Malaria
Smallpox Cardiac Adverse Events Report
Training-related injuries
Leishmaniasis
Traumatic Brain Injury
Post Traumatic Stress Disorder
MHS Dashboard Measures
FHP QA Measures
Wounded Service Members
Vaccine Adverse Events
Special Surveillance: Amputations, DVT, Leish, ARDs
Injury Installation Reports
Lost duty
Meningococcal Report
53
28
11
5
4
0 (quarterly)
1
1
1
1
3
1
1
1
1
2
1
1
2
1
# Unique Reports
7
18
3
2
1
0 (quarterly)
1
1
1
1
3
1
1
1
1
2
1
1
2
1
 Over 50 routine reports distributed monthly, quarterly, weekly, or
daily (1448 total reports annually)
 Over 600 requests performed annually
UNCLASSIFIED
Epidemiology and Analysis
Quarterly Deployment Health Report
October 2010, page 6 of 16
UNCLASSIFIED
Request Process
Request arrives at AFHSC
Assign to Liaison
Clarify question, draft analysis plan
RESEARCH
Status determination
PUBLIC HEALTH
PRACTICE
Analysis plan
presented at R3
IRB
Coding &
output
Review, approval
and delivery
De-identified
dataset
Summary
table
UNCLASSIFIED
Request Process
Requestor Contacts AFHSC
• Service liaisons
– Army
– Navy,
• Marine Corps
• Coast Guard
– Air Force
• Special Projects lead
• Residency Program
• Communications Center
• Other staff interactions
UNCLASSIFIED
Request Process
Clarify the Question
Can We Do It?
• Legal
– DMSS is System of Records
– Human Subjects Protection
– Classified or Privacy Protected
• Scientifically Sound (Methods Valid)
• Data/Sera Available
UNCLASSIFIED
Request Process
Clarify the Question
Should We Do It?
• Requestor’s Intent & Authority
• Militarily Relevant
• Military Sponsor
• Level of Surveillance (Strategic vs Unit)
• Intent
– Related to Public Health
– Purpose (Scope of Responsibility)
– PH Practice v Research
UNCLASSIFIED
Request Process
Request arrives at AFHSC
Assign to Liaison
Clarify question, draft analysis plan
RESEARCH
Status determination
PUBLIC HEALTH
PRACTICE
Analysis plan
presented at R3
IRB
Coding &
output
Review, approval
and delivery
De-identified
dataset
Summary
table
UNCLASSIFIED
Types of Requests
• “Operational”
– Strategic
– DoD-wide
– Public Health Practice
• Research
– Support
– Internal research
UNCLASSIFIED
Public Health Practice
• Specific authorization
• Accountability to the public
• May legitimately involve persons who did not volunteer to
•
•
participate
Draws on the principles of public health ethics by focusing on
populations while respecting the dignity and rights of
individuals
May be distinguished from research on the basis of general legal
authority, specific intent, responsibility, participant benefits,
experimentation, and subject selection
UNCLASSIFIED
Public Health Practice
Primary intent
• Prevent or control disease or injury and improve health
• Benefit is to the population from which information is gathered
• Military PH Practice
– Commanders, supervisors, individual Service members, and MHS
shall promote, improve, conserve, and restore physical/mental wellbeing…across the full range of military activities and operations
– Conduct activities common to other public health agencies,
including disease/injury surveillance, “reportable medical event”
case reporting, outbreak investigation, program evaluation etc.
UNCLASSIFIED
Public Health Research
Primary intent
• If to generate or contribute to generalizable knowledge, then
•
•
research
If to prevent or control disease or injury or improve a public health
program, then non-research (= PH practice = “operational”)
If changes from prevention or control to generating generalizable
knowledge, then it becomes research
UNCLASSIFIED
Request Process
Request arrives at AFHSC
Assign to Liaison
Clarify question, draft analysis plan
RESEARCH
Status determination
PUBLIC HEALTH
PRACTICE
Analysis plan
presented at R3
IRB
Coding &
output
Review, approval
and delivery
De-identified
dataset
Summary
table
UNCLASSIFIED
Request Process
• Draft Analysis Plan
UNCLASSIFIED
Request Process
Present to Request/Report Review (R-3) Team
• Epidemiology & Analysis Chief
• E & A Asst Chief
• Service liaisons
• Science advisor
• Senior Epidemiologists
• Senior Biostatisticians
• MSMR staffer
• Others ad hoc
UNCLASSIFIED
Request Process
R-3 Presentation (“Morning Rounds”)
• S: Requestor, Question
• O: Background material, supporting
•
•
literature, military relevance, etc.
A: Public Health Practice or Research
P: Analysis Template
UNCLASSIFIED
Request Process
R-3 Team Review
• R-3 Team questions the presenter
• Presenter may need to further clarify
the question (to R-3 or with customer)
– Can we do it
– Should we do it
• New R3 approval process, if needed
UNCLASSIFIED
Request Process
Request arrives at AFHSC
Assign to Liaison
Clarify question, draft analysis plan
RESEARCH
Status determination
PUBLIC HEALTH
PRACTICE
Analysis plan
presented at R3
IRB
Coding &
output
Review, approval
and delivery
De-identified
dataset
Summary
table
UNCLASSIFIED
Request Process
Analysis
• Once approved by R-3, assignment to analyst
• Coding
–
–
–
–
–
–
Complicated person-time calculations
Complex case definitions
Multiple/complex outputs
Modifications to original request
Prioritization with other requests
Technical difficulties
• May need to return to R-3
UNCLASSIFIED
Request Process
Request arrives at AFHSC
Assign to Liaison
Clarify question, draft analysis plan
RESEARCH
Status determination
PUBLIC HEALTH
PRACTICE
Analysis plan
presented at R3
IRB
Coding &
output
Review, approval
and delivery
De-identified
dataset
Summary
table
UNCLASSIFIED
Request Process
Analysis
• Output
– De-identified data set
– Summary table
• Deliver to customer
UNCLASSIFIED
AFHSC Example
H1N1 Influenza Response
UNCLASSIFIED
Detection of Pandemic Flu (pH1N1)
ESSENCE Cases
First ESSENCE
Alert (26 Apr 09)
2009
Navy FM (1st
case) presents
in San Diego
37 Sailors
present in San
Diego
2 Army FM
present in San
Antonio
March
April
May
UNCLASSIFIED
June
July
Pandemic Influneza
• First four cases of pandemic H1N1 detected in two
AFHSC/GEIS funded laboratories
– Specimens and information provided to CDC
• Three DoD pH1N1 strains used by WHO as potential seed
strains; one was selected
• Supported the diagnostic confirmation of the first H1N1 cases
in 14 different countries (US, Bhutan, Cambodia, Djibouti, Kuwait,
Kenya, Lao People’s Democratic Republic, Lebanon, Egypt, Nepal, Colombia,
Ecuador, Peru, Republic of the Seychelles)
• Numerous pH1N1 laboratory capacity building for diagnosis
– NAMRU-3: 30 countries and 70 participants in 3 weeks!!!
UNCLASSIFIED
Communication: DoD Global Influenza Activity
Samples Received: Total= Cumulative Samples since 1 September 2009, New=Previous Two Week Period
USAFSAM
TOTAL
6,293
Flu A:
LRMC/CHPPM
(NEW)
TOTAL
TOTAL
1,289 (164)
Flu A:
H1N1:
1
TOTAL
3,495
(80)
13
pH1N1:
(1)
H3N2:
pH1N1 1,122 (165)
TOTAL
CONUS
MEDCENs
TOTAL
NAMRU-3
TOTAL
2,576 (508)
1,729
(NEW)
Flu A:
793 (122)
Flu B:
15
8
H3N2:
24
Flu B:
30 (11)
Flu B:
4 (1)
TOTAL
H3N2:
pH1N1:
Flu A:
H1N1:
H1N1:
H3N2:
H3N2:
pH1N1 : 342 (21)
pH1N1 :
Flu B :
Flu B:
2
(NEW)
2
AFRIMS
TOTAL
2 (1)
Guam
(NEW)
5
733
TOTAL
11
Flu A:
(NEW)
1666
Flu A:
101
284 (53)
TOTAL
288
11
260 (96)
Flu A:
H1N1:
3 (2)
H3N2:
21 (12)
pH1N1:
Flu B:
pH1N1:
68
Flu B:
4 (3)
16
pH1N1:
147 (29)
(4)
70 (7)
NAMRU-2
TOTAL
(NEW)
1503
H1N1:
H3N2:
Flu A:
pH1N1
H1N1:
Flu B:
H3N2:
58
pH1N1:
107
225
H5N1:
Flu B:
DoD Research Labs
(NEW)
Note: H5N1 (positives/tested or pending) results are cases that have been
confirmed and reported through WHO in compliance with the
International Health Regulations 2005.
3
H1N1:
H3N2:
5
H3N2:
Flu B:
Medical Centers/Clinics
17
5
363 (30)
Flu A:
DoD Service Labs
3
22 (1)
48
USAMRU-K
H1N1:
NMRC-Lima
pH1N1
46
91
37
H5N1:
Flu A:
H3N2:
(NEW)
H1N1:
Flu B:
H1N1:
pH1N1:
369
H1N1:
(NEW)
562
H3N2:
pH1N1:
TOTAL
Flu A:
(NEW)
8,279 1,740
Flu A:
(NEW)
615
H1N1:
TOTAL
CENTCOM-Mil
Flu B:
507
H1N1:
TAMC
162 (92)
(NEW)
Flu A:
Flu B:
Flu B:
Flu A:
H3N2:
pH1N1 1,885
USF Japan
(NEW)
1,098 164
167
H1N1:
H3N2:
NHRC
USF Korea
(NEW)
472
60
2
Communication: Surveillance
Partner Reporting
Sentinel Surveillance
Population-Based/Recruit
Electronic Military Health Surveillance
DOS Embassy
Lab-Specific
Regional
UNCLASSIFIED
Communication: Network Summary
Available at: http://www.afhsc.mil
ü60
UNCLASSIFIED
2009 pH1N1: AFHSC Coordination
Attributes Combined Under One Roof
•
Laboratory network: Global visibility
•
Reportable Medical Events: Uniformed
personnel visibility
•
Conference call coordination
•
Daily/weekly reporting for chain of command
UNCLASSIFIED
Intelligent Medicine
• “…‘intelligent medicine’ that will give physicians the
tools they need to regain control over medical decisions
made for their patients.”
“A Path to Intelligent Medicine” Walter Eisner, from Rick Guyer, MD; outgoing President of
the North American Spine Society, farewell speech at annual meeting, October, 2007
UNCLASSIFIED
Intelligent Medicine
• “…bringing real thought to bear on our prevention and
treatment strategies, not just falling back on the
conventional treatment, whether high-tech or alternative,
in a knee-jerk reaction;”
– …in charge or your own health and fitness”
– A guide for patients to “help their doctors” and wisely use the
medical and preventive options available in the current
environment.
Ronald Hoffman, MD Intelligent Medicine: A Guide to Optimizing Health and Preventing
Illness for the Baby-Boomer Generation, 1997, Simon and Schuster
UNCLASSIFIED
Intelligent Military Medicine
• Evidence based policy and prevention strategies
for the United States Armed Forces
UNCLASSIFIED
Questions
UNCLASSIFIED